Surgical approach and oncological outcomes in Siewert type II junctional tumors

Optimal surgery for Siewert type II tumors remains controversial. We compared outcomes between transthoracic esophagectomy (TTE) and extended total gastrectomy (EG) in a high-volume center. This study included consecutive patients with Siewert type II tumors undergoing curative-intent surgery between 2013 and 2023. Patients treated with TTE or EG were analyzed. Primary outcomes were oncological parameters (lymph node yield, margin length, R0-rate, positive lymph nodes). Secondary outcomes included postoperative morbidity, overall survival (OS), disease-free survival (DFS), and recurrence patterns. Survival was analyzed using Kaplan-Meier and multivariable Cox regression. A total of 136 patients were included (TTE n = 71; EG n = 65). Baseline characteristics were largely comparable. TTE resulted in a significantly higher median lymph node yield (45 vs. 28, P < 0.001) and longer proximal margins (P < 0.001). R0 resection rates were similar (94.4% vs. 86.0%, P = 0.217), as was the number of positive lymph nodes. Clavien-Dindo ≥3b complications occurred in 38.0% vs. 38.5% (P = 1.000). Median OS was 2.9 years in both groups, with no difference in OS (log-rank P = 0.611) or DFS (log-rank P = 0.530). On multivariable analysis, surgical approach was not associated with OS (aHR 1.08, 95% CI 0.64-1.82), whereas advanced pathological stage (pT3-4) independently predicted worse survival (aHR 2.03, 95% CI 1.18-3.51). Despite differences in lymph node yield and proximal margin length, TTE and EG provide comparable oncological and survival outcomes in Siewert type II tumors. These results were sustained even after multivariate adjustment. These findings support an individualized, multidisciplinary approach to surgical strategy selection.